Polycystic ovary syndrome — structured oral station (12 minutes)

Opening prompt — "How do you establish the diagnosis?"

Model response — say it in this order: ^[1][2]

• "I would apply the Rotterdam criteria: any two of three — oligo/anovulation, clinical or biochemical hyperandrogenism, and polycystic ovarian morphology or elevated anti-Mullerian hormone — after exclusion of mimics. She has oligomenorrhoea and hirsutism, so she already meets two of three."^[1]
• "Crucially, PCOS is a diagnosis of exclusion. I would send a morning 17-hydroxyprogesterone to exclude non-classic congenital adrenal hyperplasia, plus TSH and prolactin, and a calculated free testosterone or free androgen index."^[6]
• "I would only request a transvaginal ultrasound if I needed a third criterion — it is not required when two are already present."^[2]

Examiner is listening for: two of three, after exclusion, and the specific exclusion tests.

Probe 1 — "Her glucose tolerance test shows impaired glucose tolerance. What does that mean for her?"

• "Women with PCOS have a markedly higher prevalence of impaired glucose tolerance — the Kakoly meta-analysis found an OR of 3.26, and type 2 diabetes an OR of 2.87, versus controls, with the highest prevalence in Asian populations."^[4]
• "So lifestyle intervention is first-line and foundational — energy-restricted eating and regular physical activity improve insulin sensitivity. I would also protect her endometrium, since her cycles are over 40 days and anovulation means unopposed oestrogen."^[2]

Probe 2 — "She wants to conceive. What is your fertility plan?"

• "Lifestyle optimisation first, then letrozole as first-line ovulation induction, with ovulation tracking."^[2]
• "The evidence is the PPCOS trial: letrozole achieved a higher cumulative live birth rate than clomiphene — 27.5% versus 19.1% (rate ratio 1.44, 95% CI 1.10 to 1.87) — with a higher ovulation rate (61.7% versus 48.3%). The 2023 International Guideline made letrozole first-line on this basis."^[3]
• "If letrozole fails, I would move to low-dose gonadotrophins with OHSS mitigation, then laparoscopic ovarian drilling or IVF with an OHSS-prevention protocol — PCOS carries a higher OHSS risk."^[2]

Probe 3 — "She asks whether metformin will help her conceive."

• "The Endocrine Society guideline is clear that metformin is beneficial for metabolic and glycaemic features but has no benefit in treating infertility. So I would not offer it as a fertility drug."^[6]
• "It may have a role as an adjunct for her glucose intolerance alongside lifestyle, but letrozole is the fertility agent."^[6]

Probe 4 — "She is tearful and says she feels unfeminine and depressed."

This is a scored domain, not a courtesy. Demonstrate it out loud: ^[5]

• Acknowledge her distress at eye level: "What you are feeling is very common in PCOS, and it is not your fault. Let's make sure we look after your mood as well as your cycles."
• "The Cooney meta-analysis found women with PCOS have about a 3.78-fold higher odds of depressive symptoms and a 5.62-fold higher odds of anxiety. I would screen with a validated tool like the PHQ-9 and GAD-7 and refer to psychological support."^[5]
• Avoid minimising her appearance concerns and avoid framing the diagnosis around weight alone.^[2]

Probe 5 — "What will you do for her long-term?"

• "PCOS is a lifelong condition managed by life stage, not cured. I would arrange periodic glucose tolerance testing, lipids, blood pressure and weight surveillance, and ongoing mood screening."^[2]
• "I would coordinate her care with a multidisciplinary team — gynaecology, endocrinology, dietitian, psychology, and primary care."^[2]